There They Go Again

If you dislike ClaimCheck, the ubiquitous program of choice that health insurers use to edit and bundle your claims, you probably are going to have some reservations about Symmetry.

Symmetry is the next-generation software tool that health plans can use to monitor and analyze a physician's claims history to determine his or her cost "efficiency." Using complex data collection and sophisticated analysis of physician care gleaned from submitted claims, Symmetry can create a profile of appropriate treatment adjusted for factors such as location, severity, complications, and quality of service that identifies doctors whose care costs more than the insurance company thinks it should. Insurers can then refuse to add these physicians to select networks or weed them from their contracted networks.

Already two of the state's major health insurers are using the software tool with an eye to creating super-networks free of expensive doctors. The super-networks will be marketed to large subscriber employers, such as state government benefit systems and self-funded employer health plans.

Aetna Inc. is assembling its Aexcel Network of specialists in the Dallas area for Fortune 500 companies with self-funded preferred provider organization and point-of-service health plans. It will be offered to similar companies in selected markets nationwide, and Aetna has signed up several Fortune 100 companies that will access the network through Aetna's management of their self-funded health plans.

Blue Cross and Blue Shield (BCBS) of Texas is designing a Symmetry-driven network for clients such as the Texas Employee Retirement System (ERS). BCBS Texas officials say that the BlueChoice Select network has not received approval from ERS, but BCBS Texas was asked to investigate several possibilities to save the state $100 million in health care costs in 2004.

Large employers are attracted to such programs because "small reductions in health care cost trends can be worth millions of dollars to them," says Carl King, Aetna's regional manager for the Southwest. Mr. King suggested that while many physicians fear evaluations of their efficiency that are based solely on economic criteria, Aexcel is designed to first eliminate the super-networks physicians who treat low numbers of Aetna insured patients and those with quality problems (i.e., defined by Aetna as those with high hospital readmission rates and/or adverse clinical events) before economic criteria are applied to identify outliers.

"There's a lot of buzz in the payer community about how to compare physician efficiency," said J. Darren Rodgers, BCBS Texas divisional senior vice president for health care management. "The industry is always looking for the next tool to help curb rising health care costs."

Some physicians fear that such measures of "efficiency" will lead to their exclusion from networks that service the largest employers in their area, crippling their practices.

Dave W. Kittrell, MD, an obstetrician and gynecologist from San Antonio who is vice-chair of the Texas section of the American College of Obstetricians and Gynecologists, is one of those who has doubts.

"It's not unusual in obstetrics to have patients who demand sonograms," Dr. Kittrell noted. "Sometimes one sonogram may be required, but some patients need more. If these produce costs that are a factor in economic credentialing, we will have some physicians who provide quality care dropped from the networks."

More worrisome to Dr. Kittrell is the effect that such screening of physician efficiency could have on patients. "This will have a major impact on the health care of women in that it provides another incentive not to take high-risk or complex patients," he said.

Dr. Kittrell also predicted that screening by insurers would affect other decisions by physicians, such as which hospital to use. Currently, Dr. Kittrell and his partners prefer to admit patients to a nearby hospital that is convenient for the physicians and patients and has good security, a concern to many of the women physicians and patients who leave the hospital at night.

"So the choice is whether we take patients to other, cheaper hospitals so that we don't get deselected," Dr. Kittrell said, noting that many physicians don't even know what a hospital charges a patient.

Dr. Kittrell, a board member of the Texas Medical Liability Trust, also wonders whether judging doctors on their economic efficiency will impact the care patients receive.

"Economic factors could once again affect liability," Dr. Kittrell said. "Doctors may try to be too frugal in order not to be deselected, and get themselves and their patients into trouble. It used to be that for insurers the choice of physicians was a matter of quality for them and the patients. Now the choice is a financial concern."

Lewis Foxhall, MD, chair of the Texas Medical Association's Council on Socioeconomics, said the council was "very concerned about this approach to credentialing" after hearing a BCBS Texas presentation on the Symmetry-based system at the TMA Summit in September. Dr. Foxhall says the council would continue to monitor the situation as the networks are assembled.

Creating Aexcel

Mr. King says maintaining quality in its physician networks is a major concern of both Aetna and the employers who use them.

"What's happening today is that employers are struggling with rapidly rising health care costs while trying to maintain access to quality doctors," Mr. King said. The Aexcel network will offer the employers a chance to do that, he adds.

On Jan. 1, 2004, Aetna will roll out the network in the Dallas/Fort Worth area, north Florida, and near Seattle. Other areas with large employers offering self-funded health plans will be added throughout 2004 and 2005.

Aexcel is built around limiting the participation of physicians in six specialties: cardiovascular medicine, cardiothoracic surgery, gastroenterology, obstetrics-gynecology, orthopedics, and general surgery.

Screening starts with volume analysis. Doctors who have treated fewer than 10 episodes for Aetna-insured patients over the previous two years will not be admitted to the network."We need enough events to produce a credible measure of efficiency," Mr. King explained.

Additionally, the Aexcel physicians will have to be board certified in their specialty and pass a quality screening that analyzes the readmission rate of their patients and an "adverse event" rate that measures complications and other unexpected medical outcomes.

"We don't look at efficiency until after we look at a physician's volume and qualityfactors," Mr. King noted.

Symmetry software identifies episode treatment groups that allow comparisons among physicians based on how expensive their treatment is.In determining the expense, each episode is adjusted by such factors as case mix, severity, the age and gender of the patient, place of service, and type of admission.

For Aexcel, a physician who averages more than 200 percent of the expected efficiency -- a measure that relates average cost to treatment costs of other physicians -- will be excluded from the network.

In creating the Texas network, Aetna found that the Aexcel network would include 70 percent of the physician specialists contracted to the insurer's other plans and networks. Of the doctors who were not admitted, 22 percent failed because they did not see enough patients to qualify, and the other 8 percent were excluded for their economic or quality performance, Mr. King says.

"Ours is a very measured approach," he said. "We only excluded significant outliers after making adjustments to reflect the complexity of the patients they are managing."

How to Save $100 Million

The Texas ERS asked BCBS Texas to find ways to save the state government $100 million in health care costs, and it quickly focused on creating a network that used physicians who were close to their local averages in fees and treatment expenses.

"What we have now is really a working model that will need state approval before it is implemented," said Mr. Rodgers. "It allows us to compare physicians to others within their specialty and within their region."

Mr. Rodgers says BCBS Texas is using Symmetry profilers in software from McKesson Corp., the manufacturer of ClaimCheck. Symmetry reviews claims and creates "episodes" adjusted for a number of factors that then allow comparison.

Because of the endless variations in treating patients with differing severity of various ailments in different areas of the state over different lengths of time, comparisons of physician performance are complex. But Symmetry's innovation is the creation of analysis units called episode treatment groups (ETGs) that describe cost efficiency of treatment, Mr. Rodgers says.

Mr. Rodgers is aware of physicians' resistance to health plans' efforts to use cost effectiveness as a screening criteria for networks. And he is quick to explain that the idea of controlled networks is not the "economic credentialing" that doctors railed against a few years ago.

"The way most physicians remember economic credentialing is that it was just about money, and there was no adjustment," Mr. Rodgers said. "That's not the case with this network. There is a quality component."

He says the insurer will follow state regulations that require it to publish its criteria for selecting physicians in advance, explain how the criteria were chosen, and provide physicians with a process to appeal selection decisions.

Mr. Rodgers says he believes Symmetry will accurately capture the costs of different kinds of episodes. Referring to Dr. Kittrell's example of the varying use of sonograms in prenatal care, Mr. Rodgers said each use of the sonogram would be included in the episode of care. If all obstetricians are faced with the same requests and demands across their patient base, the efficiency of the physicians "will even out," Mr. Rodgers said. That's because outliers will be judged on the adjusted average of services provided within their specialty, not on a median or on an estimated cost.

BCBS Texas officials have been proselytizing at state, county, and specialty medical societies, and found that physicians are concerned for their medical peers, Mr. Rodgers says. "The response is positive when we go through the system in detail," he said, "but we aren't going to have that opportunity with most doctors in Texas. They will get a letter."

Mr. Rodgers told the TMA Council on Socioeconomics at the TMA Summit in September that the BlueChoice Select network will be created within the existing BlueChoice model, which encompasses an estimated 72 percent of physicians in the state. Mr. Rodgers expects the new network to be 30 percent smaller than BlueChoice.

But one question framed the issue that keeps rising in all attempts to manage care and limit costs. "Is patient satisfaction a component in the selection of physicians for the network?" a council member asked. "No," answered Mr. Rodgers.

SIDEBAR

Symmetry Info on the Web

Symmetry Health Data Systems Inc. declined comment for the article, preferring to let the health insurance companies using its products speak for themselves. However, Symmetry, which is owned by UnitedHealthcare Inc.'s Ingenix subsidiary, maintains a Web site with detailed information about the program and its uses. www.symmetry-health.com.